PROJECT SUMMARY Improving the management of major depressive disorder is one of the great challenges confronting our health care system. Although continuous antidepressant treatment reduces relapse and symptom recurrence, early treatment discontinuation is common and slows recovery. There is a pressing need to develop new, acceptable, and easily implemented strategies to optimize treatment continuity and improve the clinical course of adults with major depressive disorder. In several medical contexts, direct patient financial incentives increase beneficial health behaviors, including medication adherence. Yet uncertainty exists over the durability of behavior change that is effected by financial incentives and the optimal design of such incentives. In the care of major depressive disorder, it may only be necessary to provide incentives early in treatment until the patients' mood begins to lift and treatment adherence becomes self-reinforcing. This pilot study tests two theory different incentive schedules for daily antidepressant adherence. It will compare usual care with either modest time-limited escalating or de-escalating financial incentives with respect to their effects on daily antidepressant adherence and depressive symptoms among non-elderly depressed adults initiating antidepressant treatment. The primary aims are 1) to compare short-term (6 weeks) effects of financial incentives on adherence to antidepressant treatment, depressive symptoms, and quality of life; 2) to determine whether the incentives, which end at 6 weeks, continue at 12 weeks to influence these patient outcomes; and 3) to assess potential negative effects of the incentives on perceived coercion, regret over study participation, trust in the treating psychiatrist, and patient participation in depression care. We will also explore whether present bias and risk aversion moderate the effectiveness of the two incentive schedules. Adult mental health outpatients ( N -= 120) with major depressive disorder who have been prescribed antidepressants will be randomly assigned to: 1) usual care, 2) usual care and escalating daily rewards for daily antidepressant treatment ($2, $3, $4, $5, $6, and $7 in weeks 1 through 6) or 3) usual care and de-escalating incentives from $7/day to $2/day for each day of antidepressant adherence with weekly decrements. Daily antidepressant adherence will be measured with a wireless electronic pill bottle, patient self-report, and physician orders. Baseline, six week, and twelve week assessments will be performed of depressive symptoms, quality of life, perceived coercion, regret over study participation, trust in the treating psychiatrist, and participation in depression care. The results of this pilot study will yield important new information on cognitive and motivational barriers to antidepressant adherence in major depressive disorder.